MEDICARE: JOHN ANTHONY MCCOLLUM LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	A2308023	AR
2	101YP2500X	Professional Counselor	P2506006	AR

General Provider Information

NPI Number	:	1033994595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN ANTHONY MCCOLLUM LAC

Provider Business Mailing Address
First Line	:	P.O. DRAWER 2109
Second Line	:
City	:	RUSSELLVILLE
State	:	AR
Zip	:	72811-2109
Country	:	US
Telephone Number	:	479-967-2322
Fax Number	:	479-967-2876

Provider Business Practice Location Address
First Line	:	5003 OLD GREENWOOD RD STE B
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-6924
Country	:	US
Telephone Number	:	479-280-9980
Fax Number	:	501-421-2336

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2023
Last Update Date	:	06/10/2025

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